1This article is largely based on work carried out by Ms Jane MacAskill for FAO as part of the United Nations Study on the Impact of Armed Conflict on Children, and her experiences in the Sudan and Somalia. For the United Nations study she undertook field visits to Liberia and the southern part of the Sudan and participated in drafting the final report. Her contribution is highly appreciated.

As a result of armed conflicts in the past decade, an estimated 2 million children have been killed, three times as many have been seriously injured or permanently disabled, and countless others have witnessed or taken part in violent acts. Even greater numbers have died from malnutrition and disease during such crises. The destruction of food crops, water supplies, health services, families and communities takes a heavy toll on children. In 1995 alone, 30 major armed conflicts raged within different states around the world (Machel, 1996).

Concerned by the miserable plight and suffering of children during armed conflicts, the United Nations General Assembly, at its forty-eighth session in December 1993, requested that a comprehensive study be undertaken on the impact of armed conflict on children. The study was to include recommendations for the amelioration of this grave situation. FAO contributed to the effort by assessing the impact of armed conflicts on the nutritional status of children (FAO, 1996).

The FAO study took account of the broad causes of malnutrition such as inadequate household food security resulting from disruption of agriculture and food distribution systems and lack of access to food; poor health care and environmental sanitation; disruption of families and their caring practices; and socio-economic and nutritional vulnerability. Coping strategies employed by the households were also examined. The breakdown of the family unit was given particular attention, since this predicament most seriously impedes the provision of food, nutrition, health services and care to children. The FAO analysis was based on discussions with United Nations organizations and non-governmental organizations (NGOs), a review of the existing literature and field experiences in several African countries.

IMPACT OF SOCIAL CONFLICTS

The nutritional situation before the conflict and the factors that cause malnutrition among children during peacetime - i.e. inadequate household food security, poor diet, insufficient health services, unsanitary environment and inadequate maternal and child care practices - are all accentuated and exacerbated during armed conflict. This id particularly true if the situation has turned into a "complex emergency", defined by the United Nations as a humanitarian crisis in a country, region or society where there is a total or considerable breakdown of authority resulting from internal or external conflict. Complex emergency situations require an international response that goes beyond the mandate or capacity of any single agency or ongoing United Nations country programme.

During emergencies many people are forced out of their homes. They often lose most of their possessions and face months and even years of misery. Some are temporarily dependent on international assistance for their protection and survival. Others may require food relief and assistance in obtaining resources to produce food for many years until the conflict has been resolved and the situation is conducive to a return to stable life where rehabilitation and development are possible. It should be recognized that in conflict situations those people who remain in their home areas may be as vulnerable to nutrition problems as those who have left; however, they may not receive as much international attention because many relief agencies are not mandated to assist them. Furthermore, the security situation may prevent relief agencies from reaching people to assist them.

In addition, infrastructure, health and sanitation facilities are often damaged or destroyed. Communities' food resources are stressed since the capacity to ensure availability of food and people's access to it generally becomes highly uncertain. In particular, the recurrent displacement of families reduces people's ability to support themselves and increases the level of trauma and stress within the community. This instability may adversely affect care and feeding practices for children. Loss of parents and other family members clearly affects children's access to food, shelter and support. Thus, armed conflicts bring forth a broad range of factors increasing children's vulnerability to malnutrition.

INSUFFICIENT HOUSEHOLD FOOD SECURITY

Household food security during armed conflict is affected by a combination of factors including decline of agricultural production because of physical insecurity; lack of agricultural inputs and extension services; destruction of food processing, storage and distribution systems as well as roads and markets; and loss of income coupled with rising prices. In rural areas, displacement or death of working family members, loss of draught animals, lack of food to provide adequate dietary energy for work and increasingly often the threat of land mines can prevent sufficient land from being cultivated and harvested. All of these factors affect both the quantity and quality of the food that is available to families (see Figure).

During conflicts the availability of staple foods and the variety of foods grown may be reduced. Families may face a lowering of income, which decreases the possibilities of buying additional food or improving production. In pastoral populations, conflict may lead to loss of access to pastures and water, resulting in loss of livestock, income and access to food. Consequently, children's access to a diversified diet containing adequate levels of energy, protein, vitamins and minerals is seriously diminished (FAO, 1996). City dwellers and large concentrations of displaced persons may also be extremely vulnerable to such disruption in the food system and incomes and may become totally dependent on outside assistance.

Four years after the conflict in the Juba Valley in 1991 and the subsequent
displacement of many people to cities such as Mogadishu and Kismayo and
to refugee camps in northeastern Kenya, production levels for the main
harvest in that area were still estimated to be 40 to 50 percent less
than pre-war levels (FAO, 1996).

Upon their return to rural areas, families found their land overgrown
with bushes which severely reduced the area that could be planted during
the first planting season. Clearance of the land was time consuming and
difficult, and access to seeds and tools was limited. The occasional periods
of insecurity led to more cautious and restrictive planting strategies;
farmers planted close to their villages for fear of being attacked. Agricultural
infrastructure such as the flood control systems for control of the Juba
River and irrigation systems in banana plantations as well as food processing
equipment such as grinding mills had been destroyed, looted or damaged.
Agricultural extension services, which in the past had been provided by
the Ministry of Agriculture, were no longer available because the ministry's
infrastructure was destroyed, services had collapsed and many agricultural
extension workers had fled.

Meanwhile, the population of Mogadishu exceeded 1 million people by 1995.
A nutrition survey conducted in June 1995 reported that moderate and severe
malnutrition (wasting) had risen to 20 percent among the resident and
displaced population groups, compared with 7.5 percent in 1993. No significant
difference in nutritional status was found between the displaced and resident
populations, since lack of employment and decreased access to income,
the major contributors to the high rates of malnutrition, affected both
groups (FAO, 1996).

Malnutrition in Mogadishu, Somalia

Agency

Year

Percent <80% WFHa

Sample size

United Nations Children's Fund (UNICEF)

1988

3.4

210

2.4

210

6.0

168

5.0

210

Somalia Ministry of Health/Save the Children Fund - UK

1993

7.5

30 clusters of 30 families (1 per family)

Action Internationale centre la Faim (AICF)

1995

20.0

30 clusters of 30 children (displaced)

AICF

1995

20.4

30 clusters of 30 children (resident)

aWFH: weight for height. Results in Z score only available for 1995 survey.

COPING DURING CONFLICT

To assess the impact of armed conflicts on the nutritional situation of children, an understanding of survival strategies used by households in times of conflict is required. This involves comprehension of the major factors causing households to become vulnerable to food insecurity and malnutrition in conflict situations as well as of the coping mechanisms employed by people to overcome the crisis and the effects of these mechanisms on their children's lives.

When households are in danger of becoming food insecure, they employ various types of coping strategies to maintain their access to food and to protect their livelihoods during the crisis. They may collect wild foods, look for credit, sell their labour or reduce consumption. People's reactions depend mainly on their perception of the severity of the crisis and their economic and social position.

In deciding which options to employ, a household will carefully weigh the economic and social costs of each action, although during conflicts people may be forced to take greater risks more suddenly, since their first goal is to save lives. In addition, freedom of movement is often restricted because of insecurity, which limits access to foods. Collection of unfamiliar wild foods can be risky; many contain natural toxins, and when procedures for their preparation and utilization are unknown, their consumption may lead to toxicity and poisoning. Very often homes and farms are destroyed when people flee their home area, which makes it extremely difficult for them to re-establish normal lives when they are able to return to their home communities. In addition, many of the economic and social networks that households normally employ during times of crisis may be shattered in conflict situations; the community or even the family may no longer be available as a safety net. Thus the range of successful coping strategies is severely limited.

FLIGHT AND LOSS OF PROPERTY IN LIBERIA

When war spread throughout Liberia, people sometimes fled the violence for periods of two to three months by going into the bush. They survived by living mainly on cassava roots and palm cabbage with the greens of sweet potato or cassava. Palm butter and oil were scarce because the situation was too insecure to permit looking for palm nuts. Collection of products from the forest was not without risk: people died from eating unfamiliar poisonous mushrooms. Malnutrition became widespread in the area. Many children suffered from swelling (oedema), and adults were later affected as well. When these individuals were able to return to their homes they found that houses had been burnt and crops looted, which made it more difficult for them to re-establish their lives (FAO, 1996).

INSUFFICIENT HEALTH SERVICES AND UNHEALTHY ENVIRONMENT

Armed conflicts seriously affect health services and the environment. Health staff is reduced because of flight, death or conscription in the military. Health care infrastructure, medical supplies, equipment, sanitation and water supplies are often destroyed. Delivery of health services, especially preventive immunization and mother and child care, is obstructed. At the same time, displacements, war trauma and physical injuries increase people's needs for health services and medical care.

The almost complete absence of health services exacerbates the situation of families whose living conditions, food supply and consumption are inadequate; thus a vicious complex of malnutrition and poor resistance to infectious diseases is initiated. The risk of malnutrition and susceptibility to infection are further aggravated by large-scale population movements and concentration of people in transit camps. Overcrowding and lack of adequate sanitation and water supplies in camps can lead to rapid spread of disease.

Loss of basic household equipment increases the risk of unhygienic food preparation and storage and water contamination. For example, loss of mosquito nets and shoes during travel may increase the risk of malaria and hookworm infection, and loss of access to fuelwood affects the preparation of food, thus increasing the risk of food contamination. All of these factors have an adverse effect on the nutritional status of children.

IMPAIRED CARING CAPACITIES

Armed conflicts seriously disrupt the caring capacity of the community and the family, and especially that of mothers. This care is vital for the protection and nutritional well-being of children. Families seek the best way to cope with the crisis and often tend to emphasize protection of livelihoods, sometimes at the expense of time devoted to child care and feeding practices. With income diversification and longer searches for water, food and work, the amount of time devoted to children will decrease. Entire families or individual family members may be forced to migrate. Distress may result in prostitution by both women and the female children or, in extreme cases, in the selling and abandonment of children (Longhurst and Tomkins, 1995).

Mothers in particular tend to have little time to attend to caring activities, since in many cases the mother has to take a different role to protect her family. Frequently when the husband leaves because of war, becomes disabled or dies, the woman becomes the head of the household, taking on extra responsibilities in decision-making and in the provision of income and food. These added tasks leave little time for breastfeeding, for preparation of weaning foods or for looking after the health needs of the children. School-age children and adolescents are left to take care of themselves and thus become vulnerable to malnutrition and social vices such as violence, theft or prostitution.

In the aftermath of war, households, especially those headed by women, have more difficulty in performing certain tasks. Women often make up a large proportion of the population after a war. After a peace agreement was signed in Cambodia in 1992, it was estimated that two-thirds of the surviving adult population was female and up to 40 percent of the households were headed by women; in some areas this proportion was as high as 69 percent (FAO, 1994). The lack of adult labour, particularly that of males, affects the capacity of the family to engage in agricultural activities and to participate in public works programmes. This problem can be very acute for returnee households which may need to carry out heavy labour such as breaking land that has not been cultivated for many years.

Protecting the nutritional status of mothers during and after a conflict situation is essential for protecting the nutritional status of infants and children. After war, the exigencies of heavy labour in the reconstruction of homes and in agriculture to rebuild livelihoods, in addition to the demands of caring for the household, children and other family members, can have adverse consequences for women's health. In general, healthy adults are needed to provide sufficient care for children. Clearly, preserving the integrity of the family and supporting women's capacity to cope with difficult circumstances, particularly during the period of reconstruction and recovery, are crucial for the nutritional welfare of children.

RESPONSE MECHANISMS

The first aim in an emergency is to provide relief interventions in order to save lives. The common humanitarian response wherever there are high rates of malnutrition and acute food shortages is food relief, usually based on initial assessments of malnutrition and mortality in combination with information on food supplies in the country. Although there is a strong link between malnutrition and child mortality in armed conflict situations or famine, it is not only the severely malnourished who die (Young and Jaspars, 1995). Death often occurs because of a health crisis when populations are displaced and are exposed to an unhealthy, often overcrowded environment subject to increased levels of infectious diseases such as diarrhoea and measles. Therefore, in order to develop effective interventions, it is essential to collect data on nutritional status and mortality, including adequate information on possible causal factors such as household food insecurity, morbidity patterns or disturbed caring practices.

Experiences in Baidoa, Somalia in 1992 showed that rapid implementation of food relief programmes alone was largely insufficient to address the existing malnutrition and mortality problems, since their main cause was not lack of food but diarrhoea and measles resulting from large population displacements into urban centres and camps. This particular situation called also for early interventions in the health sector such as measles vaccination, vitamin A distribution, sanitary measures and access to clean water. Unfortunately, these programmes became operational much later since the initial emphasis was on food relief only.

If malnutrition is related to poor access to food, relief measures tend to be limited to those addressing people's immediate needs, i.e. providing food aid. Two types of feeding programmes are commonly established when malnutrition rates are high: therapeutic feeding for severely malnourished children, and supplementary feeding (i.e. distribution of either cooked food or dry rations) aimed at treatment of moderate malnutrition. Both have their uses and limitations in effective treatment of malnourished children.

Feeding programmes are most effective, however, when they do not stand by themselves but are part of a relief or rehabilitation programme aimed at strengthening the resilience of households and rural economies. Organizing such programmes requires a broad understanding of how people usually obtain their food and how these means are affected by conflict.

USING FOOD AID IN THE SUDAN

In the southern part of the Sudan there has been a move towards utilizing food relief as a part of a wider strategy aimed at supporting community and household food security mechanisms. The assistance programme, which previously responded to crises with food relief shifted its focus towards developing an understanding of how people survive, emphasizing household food security through support to livestock production, fishing, agriculture, health, education and capacity building. Food aid in this programme is used both as an emergence response for satisfying immediate food needs and as part of activities aimed at strengthening household food security for a long-term impact on health and nutrition.

The livestock programme has concentrated on rinderpest vaccination to protect herds and thus support people's income and livelihoods. The fishing programme has initially concentrated on the distribution of hooks and fishing lines; fish is now being transported to feeding programmes, hospitals and camps. The agricultural programme started with the distribution of seeds and tools, but it is a present also supporting local seed production, vegetable production to improve the quality of the diet and promotion of appropriate technologies for processing of farm produce and improved storage

Food aid, as part of these activities, contributes to household food security in several ways: it provides an additional source of food contributes to development of markets, reduces the displacement of people, enables the return of displaced persons and lessens intratribal tensions and looting (FAO, 1996).

In a conflict situation a number of factors can seriously impede operations in response to a food crisis in a country. The political and military situation is an important determinant of the success of relief operations. For example, in February and March 1997 civil conflict in eastern Zaire (now the Democratic Republic of the Congo) blocked food aid deliveries. Large parts of the area were inaccessible to humanitarian relief agencies because of insecurity and ongoing violence. Relief workers were denied access, and an unknown number of displaced Zairian (Congolese) people and refugees from Rwanda were thus left without any assistance. Logistical problems such as lack of transport (vehicles, aeroplanes), bad roads, poor weather conditions or lack of storage facilities may also hamper assistance. Finally, a narrow perception in which food shortage is seen as the only cause of malnutrition can lead to an overemphasis on food aid, to the exclusion of other types of intervention. Each of these factors, or a combination of them, can result in prevention or delay of the delivery of appropriate relief assistance to civilians, which will be detrimental for the malnourished children waiting for help.

CONCLUSIONS

Long-standing, ongoing conflicts may affect various regions and population groups in various ways and at different times, depending on how the conflicts evolve. Droughts and floods during a conflict may easily result in an even more acute emergency, since the disruption of government structure and infrastructure, dysfunction of support services and absence of control may all lead to lack of responses or ineffective reactions to address natural crises.

Current methods of assessment of the nutritional situation in conflict situations tend to emphasize collection of nutritional and mortality data, mainly to support short-term interventions. However, it is clear that more in-depth information on all aspects of malnutrition and food insecurity is indispensable.

To implement appropriate responses for improving the nutritional status of children, information is needed on how people cope during the different phases of a conflict, on health and care conditions and on the developments within the conflict. To estimate the impact of the interventions on the nutritional status of children, it is insufficient to measure only the number of malnourished children or the morbidity and mortality at a certain point in time; it is also important to measure the frequency with which children suffer from repeated episodes of malnutrition or disease.

Assessment of the nutritional situation in armed conflicts should be designed to bring out programme concerns in a clear manner to assist in the development of appropriate responses to the nutritional needs of children living in these situations. Responses may include interventions supporting household food security and care and feeding practices, addressing potential long-term effects of undernutrition on child growth and development and confronting acute malnutrition. Moreover, as households are the most important entities in ensuring both the survival and nutritional welfare of children during armed conflicts, programmes to protect, promote and restore the nutritional status of children should be designed to maintain the integrity of households and to make them economically and socially viable.

Given the long-term nature of most conflict situations and assistance programmes implemented during times of conflict, these programmes should adopt a developmental approach: relief measures should be linked with rehabilitation and development objectives and activities, such as rehabilitation of agriculture, livestock and fisheries, to enhance local capacities to meet the community's food needs and to improve household food security. Many of the actions that are required to prevent people from becoming destitute are also fundamental to protecting the nutritional status of children in crisis situations. Apart from the provision of the inputs necessary for resuming, for example, agricultural production, a focus on using and strengthening local capacity and skills in all sectors is vital. Local organizations need to collaborate in decision-making, planning and implementation of programmes. It is very important that programmes be designed flexibly to take into consideration the impact of constant or recurring insecurity and violence on programme development. Programmes should be designed to take advantage of periods of calm and should aim at improving the capacity of the population to survive periods of crisis.

Of course, averting or stopping conflict will do more to help children and to prevent widespread acute malnutrition than any intervention implemented during armed conflict. Therefore, more efforts and resources should be concentrated on conflict resolution and on creating a climate of political will to create dialogue instead of fighting, both in countries suffering from armed conflict and in countries affected by internal violence that could eventually lead to armed conflict. The report on the impact of armed conflict presented to the United Nations General Assembly in November 1996 by Graça Machel underlines this necessity strongly by highlighting the terrible, often long-term or even irreversible consequences for children living in conflict situations (Machel, 1996). More efforts along these lines are crucial for a real improvement of today's world.

In the past decade an estimated 2 million children were killed, 6 million were seriously injured or permanently disabled, and countless others witnessed or took part in armed conflicts. Even more children died from malnutrition and disease during such crises. Wars exacerbate the conditions leading to malnutrition such as inadequate household food security, poor diet, insufficient health services, unsanitary environment and inadequate maternal and child care.

Household food supplies become highly uncertain in conflict situations. Farms and rural assets and infrastructure are damaged; agricultural production falls because of lack of inputs and extension services; food processing, storage and distribution systems are destroyed; and incomes may decrease while prices rise. Displacement or death of rural people, lack of energy for work and the physical danger of working on the land prevent cultivation and harvesting of crops and use of pasture and water wells for livestock.

Health services give priority to war-related treatment; medical staff are lost; and health infrastructure, medical supplies and equipment are destroyed. The obstruction of services for children, such as preventive immunization, leads to poor resistance to infectious diseases. The risk of infection is aggravated by population movements and the concentration of people in refugee camps.

During conflicts, economic and social networks are shattered. To cope, people collect wild foods, look for credit, sell their labour and reduce consumption. When men leave, become disabled or die, women face heavy burdens of protecting the family and providing income and food, which may jeopardize their health. Mothers have little time for breastfeeding, preparing foods or providing care to children.

Effective interventions require information on nutritional status and mortality, household food insecurity, morbidity patterns and disturbed caring practices. Emergency feeding programmes should be part of a relief or rehabilitation programme aimed at strengthening the resilience of households and rural economies.

Long-term assistance programmes should be flexible and should adopt a developmental approach to enhance local capacities to meet the community's food needs. More efforts and resources should be concentrated on conflict resolution to prevent such situations from occurring.